The Long Term Conditions Agenda Networksmultidisciplinary teams

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The Long Term Conditions AgendaNetworks/multi-di
sciplinary teams

• Claire Whittington
• Commissioning Directorate

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Aims

• Overall context
• Outline emerging proposals
• Consider how multi-disciplinary teams/networks
  supports the delivery of LTC

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The New Clinical Paradigm

• While the global disease burden has been
  shifting towards chronic conditions, health
  systems have not evolved to meet this changing
  demand. Care is fragmented, focused on acute and
  emergent symptoms, and often provided without the
  benefit of complete medical information WHO
  (2002) 1

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Range of White Paper LTC commitments

• Bigger emphasis on self care and integration
• Requirement for multidisciplinary teams/networks
• Universal case management for VHIUs
• Personal Health and Care Plans
• Whole System LTC Demonstrators
• 24/7 single point of contact for people with
  complex needs

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Direction of travel

• Increasing emphasis on care outside hospital
• Intelligent and Agile Commissioning
• Patient and Client centred care
• Information and technology as powerful enablers
• Integration - key

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international research suggests that integration
is most needed and works best when it focuses on
a specifiable group of people with complex needs,
and where the system is clear and readily
understood by service users (and preferably
designed with them as full partners). -
Integrated Care a Guide, Integrated Care Network
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White Paper commitment

• By 2008 we expect all PCTs and local authorities
  to have established joint health and social care
  managed networks and/or teams to support those
  with long term conditions who have the most
  complex needs.

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Elements of integration (WHO)

• Horizontal integration linking similar levels of
  care
• Vertical integration linking different levels of
  care
• Continuity of care user perspective ideal
  experience
• Integrated care encompassing technological,
  managerial and economic aspects of service

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Why focus on networks and teams ?

• Principle of integrated teams been around for a
  long time
• Networks to coordinate development of a service
  more recent
• Proven that both can deliver benefit
• YET
• Establishment of teams fragmented
• Networks not wide spread
• Concept unclear
• Expectations of what can be delivered through
  both confused

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How to encourage wide scale development

• Best practice guidance
• Recognise that teams and networks are distinct
  but complementary implement in parallel
• Vision for how can be used locally
• Consider barriers and how can overcome

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Networks

• Managed network involving clinicians, users,
  managers across health and social care
• Role identify needs of LTC population, look at
  care pathways to deliver optimal care and inform
  commissioning decisions
• Led by Senior Officers/Directors of PCT/LA
• All need to be accountable so governance critical
  

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Patient Care Team (Starfield)

• ..is a group of diverse clinicians who
  communicate with each other regularly about care
  of a defined group of patients and participate in
  that care

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Multi-disciplinary teams

• Bring together individuals who plan and deliver
  care across organisational boundaries to
  particular groups of users
• Combined potential of
• Individual professions
• Organisations
• Third sector partners
• Benefit
• More eyes and ears
• Insights of different bodies of knowledge
• Comprehensive, holistic view of users needs
• Wider range of skills
• Increased range and quality of services available
  integrated and seamless
• Effect
• Improved health outcomes
• Reduced costs

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What makes up a team ?

• Different team components/different user needs
• Practice/multiple practice
• Practice/specialist acute care
• Practice/specialist acute care/social
  care/housing/voluntary sector (significant
  benefit)
• Mix of skilled clinicians/educators with clinical
  and self care support skills and public health

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What makes up a team (2)

• Not prescriptive
• Consider different skills of
• GPs
• Practice nurse/specialist nurse/community matron
• Medical specialists
• Pharmacists
• Social workers
• Lay health workers
• OTs
• psychiatrists
• Voluntary sector
• Others
• Based on needs of user

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Challenges

• Management structures
• Breaking down professional silos
• Training and preparation
• Information sharing and communication
• Insufficient nurturing of teams

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Key factors for success

• Shared core roles, goals and values
• Understanding and respect for competencies of
  other team members
• Need to learn from other disciplines and respect
  their different views and perspectives
• Individual team members may need to reassess
  exclusive claims to specialist knowledge and
  authority
• Team development training
• Integrated management systems
• Formulation of operational policies

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Effectiveness of team care (Wagner)

• Population based care
• Care plans
• Self care support
• Sustained follow up
• Also supports many of White Paper commitments
• Also need to consider 24/7

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An opportunity

• How to provide a seamless and holistic service
• Redesign user centred services
• Significant role people with long term
  conditions
• Huge potential